Provider Demographics
NPI:1336671379
Name:IMPACT WELLNESS CENTER
Entity Type:Organization
Organization Name:IMPACT WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TEFYLON
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMERON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-717-9299
Mailing Address - Street 1:1989 N WILLIAMSBURG DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5998
Mailing Address - Country:US
Mailing Address - Phone:678-717-9299
Mailing Address - Fax:404-492-8885
Practice Address - Street 1:1989 N WILLIAMSBURG DR
Practice Address - Street 2:SUITE E
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5998
Practice Address - Country:US
Practice Address - Phone:678-717-9299
Practice Address - Fax:404-492-8885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA050322208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty